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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005466
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:40:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230824115015
FACILITY NAME:BROOKDALE KETTLEMAN LANEFACILITY NUMBER:
397005466
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:56CENSUS: 40DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nicole Bacon, Assistant Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not properly store food
INVESTIGATION FINDINGS:
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On 12/14/23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to facility at approximately 12:45 pm. LPA Campbell discussed the purpose of the visit and the elements of the allegation with Assistant Executive Director Nicole Bacon.

Regarding the allegation that staff do not properly store food, prepared desserts were observed by LPA Campbell to be stored uncovered in the refrigerator.

Based on LPA’s observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.

An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230824115015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87555(b)(23)
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87555(b)(23) All readily perishable foods...shall be stored in covered containers at appropriate temperatures.


This requirement is not met as evidenced by
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Licensee agrees to conduct an in-service staff training on food cycling and food dating. Licensee agrees to send LPA Campbell a copy of a sign-in sheet for this training by the POC due date. Renee.cambell@dss.ca.gov
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Based on observation, food was stored in the refrigerator uncovered.
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Type B
CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230824115015

FACILITY NAME:BROOKDALE KETTLEMAN LANEFACILITY NUMBER:
397005466
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:56CENSUS: 40DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nicole Bacon, Assistant Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
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3
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5
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9
Staff are providing expired food to residents
INVESTIGATION FINDINGS:
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On 12/14/23, Licensing Program Analyst Renee Campbell made an unannounced visit to facility at approximately 12:45 pm. LPA Campbell discussed the purpose of the visit and the elements of the allegation with Assistant Executive Director Nicole Bacon.

Regarding the allegation that staff are providing expired food to residents, no expired food was observed during a tour of the kitchen, freezer and refrigerator. Items such as milk or creamer were observed to have an expiration date of more than a month after the date of the visit

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3